STUDENT SUPPORT SERVICES

P.O Box 5053 Greeneville, TN 37743

423-798-1635 Fax: 423-787-8494 1-800-729-0256 ext. 5635

Student Support Services is funded by the U.S. Department of Education for $290,000. Certain personal

information is required; however, the information provided will be held in strictest confidence.

***NOTICE - To be considered for Student Support Services, applicants MUST attach a copy of the

parent’s 2010 tax return when submitting this application. Applications lacking tax documentation are considered incomplete and will not be reviewed. If parents did not file taxes for 2010 please call a program representative at the number listed above for information regarding completion of an Income Verification Form.

Today’s Date_________________

GENERAL INFORMATION (Please Print)

Name____________________________________________________________________________________

(Last/First/Middle)

Social Security Number_________________________________ Date of Birth________________________

College Box Number #__________ Home Phone #________________Cell Phone #_____________________

For the 2011-2012 academic year, the applicant will be: _____ an on Campus Resident _____a Commuter

Local address (if commuter)__________________________________________________________________

Citizenship: (Check one)

____U.S. Citizen ____Territory Resident ____Permanent Visa ____Other (specify)

EDUCATIONAL BACKGROUND

Previous participation in other Federal TRIO programs:

Previous college(s) attended:______________________________________________________________________

(Name/city/state)

FINANCIAL AID INFORMATION

Have you applied for financial aid? ____Yes ____No If so, are you currently receiving aid? ____Yes ____No

ELIGIBILITY INFORMATION

With whom do you live?

______Mother ______Father ______Guardian ______Spouse _____Other

Have you lived with your parents in the last year? ______Yes _____No

Does your mother/guardian have a 4-year college degree? ________Yes _______No

Does your father/guardian have a 4-year college degree? _______Yes _______No

***In order to be considered for admission into Student Support Services, applicants must submit a copy of their parents’ tax return (form 1040 or equivalent) for the current year (2010). The federal government requires applicants to provide documentation of their family’s taxable income and number of persons within the family household. This information is usually located within the first two pages of most tax forms. For 2010 forms, the taxable income amount appears on line 43 of FORM 1040, Line 27 of FORM 1040A, and line 6 of FORM 1040EZ.

Income documentation should be mailed or faxed WITH the application to the address or fax number above.

DISABILITY INFORMATION

Do you have a learning disability of any kind? ____Yes ____No

If so, have you or do you intend to inform the campus Academic Resources Center (ARC) of your learning disability?

Please list or describe your learning disability ________________________________________________________

SERVICES NEEDED

Please check all areas in which you need assistance, instruction, or information.

____Academic Advising ____Graduate School Info/Visit ____Scholarships

____Career Guidance ____Mentoring ____Computer Loan

____Computer Skills/Assistance ____Personal Counseling ____Informational Workshops

____Tutoring ____Book Loan ____Other_________________

____Cultural Enrichment ____Study Skills Enhancement

____Financial Aid Information ____Student Success Skills

STUDENT COMMENTS

Additional information you wish to share that may assist program staff in helping you:

____________________________________________________________________________________

I understand that I must utilize program services and/or activities. Prolonged inactivity (for longer than two semesters) may result in forfeiture of participation in the program.

In addition, this is to certify that I agree to waive my rights under the Family Privacy Act (Buckley Amendment), and agree to permit the Student Support Services Program staff to access academic history and financial aid and information. I understand that this information will be held in strict confidentiality and only utilized in determining eligibility and reporting performance.

I also give my permission for Tusculum College SSS to use my likeness or photographic images for program-related publications, social media, and/or public relations materials. Such items may include: newspaper releases, Facebook posts, web site images, and promotional brochures. I understand that these items will be used by Tusculum College’s Student Support Services program personnel solely for the purposes of promoting the program.

______________________________________________________________________________________

Signature Date